Introduction Infective Endocarditis Research Articles

Cardiac surgery in infective endocarditis and predictors of in-hospital mortality

Abstract Introduction Infective endocarditis (IE) is a serious disease with significant in-hospital mortality (15–30%) despite advances in medical and surgical therapy. Aims To perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in-hospital mortality. Methods We retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017. Results The median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery. Conclusions There is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Assessing efficacy of CytoSorb haemoadsorber for prevention of organ dysfunction in cardiac surgery patients with infective endocarditis: REMOVE-protocol for randomised controlled trial

IntroductionInfective endocarditis (IE) is associated with high mortality and morbidity. Multiple organ failure is the main cause of death after surgery for IE. Cardiopulmonary bypass (CPB) can cause a systemic...

Cirurgia cardíaca na endocardite infeciosa e preditores da mortalidade intra‐hospitalar

IntroductionInfective endocarditis (IE) is a serious disease with significant in‐hospital mortality (15‐30%) despite advances in medical and surgical therapy. AimsTo perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in‐hospital mortality. MethodsWe retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017. ResultsThe median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery. ConclusionsThere is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Towards identification of novel putative biomarkers for infective endocarditis by serum proteomic analysis

IntroductionInfective endocarditis (IE) has high mortality, partly due to delayed diagnosis. No biomarker can identify IE in patients with fever and clinical picture of infection. To find putative biomarkers we analyzed serum levels of two proteins found in cardiac valves, fibulin-1 (n=696) and osteoprotegerin (n=689) among patients on clinical suspicion of IE. Proteomic analyses were performed in 24 patients with bacteremia, 12 patients with definite IE and 12 patients with excluded IE. MethodsFibulin-1 and osteoprotegerin were studied by enzyme linked immunosorbent assay (ELISA). Proteomic analyses were conducted by 2-dimensional polyacrylamid gel electrophoresis (2D-PAGE) and label-free quantitative liquid chromatography - tandem mass spectrometry (LFQ LC-MS/MS). Controls for 2D 2D-PAGE and LFQ LC-MS/MS had bacteremia and excluded IE. ResultsOsteoprotegerin levels were significantly increased in IE patients compared with non-IE patients. Fibulin-1 showed no difference. 2D-PAGE showed significant differences of 6 proteoforms: haptoglobin, haptoglobin-related protein, α-2-macroglobulin, apolipoprotein A-I and ficolin-3. LFQ LC-MS/MS analysis revealed significant level changes of 7 proteins: apolipoprotein L1, complement C1q subcomponent B and C, leukocyte immunoglobulin-like receptor subfamily A member 3, neuropilin-2, multimerin-1 and adiponectin. ConclusionsThe concentration changes in a set of proteoforms/proteins suggest that stress and inflammation responses are perturbed in patients with IE compared to patients with bacteremia without IE.

Infective endocarditis after transcatheter aortic valve implantation: Contributions of a single-centre experience on incidence and associated factors

IntroductionInfective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. MethodsA retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3 months (interquartile range [IQR] 9.1–36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. ResultsEleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36–578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78 years, IQR 73–80, versus 82 years, IQR 79–84, p=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2±1.2, p<.001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, p<.03). ConclusionsIn our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.

Endocarditis infecciosa después de TAVI: aportaciones de la experiencia en un único centro sobre la incidencia y los factores asociados

IntroductionInfective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is an emerging complication. There are incomplete and disparate data on its incidence. We present the experience of a single-centre of incidence, mortality and associated factors of IE after TAVI. MethodsA retrospective observational study of IE cases in people who received a TAVI, between 06/01/2009 and 11/01/2017, in a university hospital, during a median follow-up period of 15.3months (interquartile range [IQR] 9.1-36.2). Incidence, clinical, microbiological and prognostic data, and factors associated with IE after TAVI were analysed. ResultsEleven patients with IE of 200 TAVI were detected. Global incidence: 5.5% (2.77 cases per 100 patient-year). The median of days from TAVI to IE was 112 (IQR 36-578), the in-hospital mortality rate was 36.4%, and the one-year mortality rate was 54.5%. All the organisms identified were gram-positive (4 Enterococcus faecalis, 3 coagulase-negative Staphylococcus). The patients with IE after TAVI were significantly younger (median 78years, IQR 73-80, versus 82 years, IQR 79-84, P=.002), they had a higher EuroSCORE (5.1±2.4 versus 3.2±1.2, P<.001), and they more frequently had a history of neoplasia (18.2% versus 4.2%, P<.03) ConclusionsIn our area, IE after TAVI has an incidence greater than that described in multicentre series, this is in line with the trend published in the literature. It leads to high mortality and is associated with a worse baseline clinical situation.

Endocarditis infecciosa

IntroductionInfective endocarditis (IE) is a rare but very serious and potentially lethal disease, so early diagnosis is essential. This has to be a high degree of suspicion, since on many occasions the wide range of clinical manifestations makes it difficult and delays diagnosis. DiagnosisThe profile of the patient with IE has changed during the last decades, being currently more prevalent in older patients, with more comorbidities, and more related to interventional procedures and health care. The diagnosis is based on clinical, microbiology and imaging tests, among which echocardiography stands out. TreatementAntibiotic treatment depends on the causative organism and whether the infection is based on a native valve or prosthetic. The most common microorganisms are S. aureus, coagulase negative staphylococci, streptococci (especially S. bovis and other oral streptococci), enterococci, and to a lesser extent Gram negative bacilli (in particular the HACEK group) and fungi. In many cases patients with IE require surgery to resolve the infection. The indication of antibiotic prophylaxis to prevent IE has been reduced in recent years to a small group of high-risk patients.

Hemoadsorption treatment of patients with acute infective endocarditis during surgery with cardiopulmonary bypass - a case series.

IntroductionInfective endocarditis is a serious disease condition. Depending on the causative microorganism and clinical symptoms, cardiac surgery and valve replacement may be needed, posing additional risks to patients who may simultaneously suffer from septic shock. The combination of surgery bacterial spreadout and artificial cardiopulmonary bypass (CPB) surfaces results in a release of key inflammatory mediators leading to an overshooting systemic hyperinflammatory state frequently associated with compromised hemodynamic and organ function. Hemoadsorption might represent a potential approach to control the hyperinflammatory systemic reaction associated with the procedure itself and subsequent clinical conditions by reducing a broad range of immuno-regulatory mediators.MethodsWe describe 39 cardiac surgery patients with proven acute infective endocarditis obtaining valve replacement during CPB surgery in combination with intraoperative CytoSorb hemoadsorption. In comparison, we evaluated a historical group of 28 patients with infective endocarditis undergoing CPB surgery without intraoperative hemoadsorption.ResultsCytoSorb treatment was associated with a mitigated postoperative response of key cytokines and clinical metabolic parameters. Moreover, patients showed hemodynamic stability during and after the operation while the need for vasopressors was less pronounced within hours after completion of the procedure, which possibly could be attributed to the additional CytoSorb treatment. Intraoperative hemoperfusion treatment was well tolerated and safe without the occurrence of any CytoSorb device-related adverse event.ConclusionsThus, this interventional approach may open up potentially promising therapeutic options for critically-ill patients with acute infective endocarditis during and after cardiac surgery, with cytokine reduction, improved hemodynamic stability and organ function as seen in our patients.

Bacteremia after Endodontic Procedures in Patients with Heart Disease: Culture and Molecular Analyses

IntroductionInfective endocarditis (IE) is still associated with high mortality, and antibiotic prophylaxis strategies are under intense debate. We evaluated the incidence of bacteremia after root canal preparation in teeth with necrotic pulps and apical periodontitis. MethodsBlood samples were taken before and 5 and 30 minutes after endodontic treatment in teeth with apical periodontitis from individuals at high (n = 21) or no risk (n = 11) for IE. The former received prophylactic antibiotic therapy. Bacteriologic samples were taken from root canals before chemomechanical preparation to confirm pulp infection. Samples were subjected to aerobic and anaerobic culture and quantitative real-time polymerase chain reaction (qPCR), the latter to determine the total bacterial and streptococcal levels. ResultsCulture revealed no bacteremia in all individuals. Analysis by qPCR showed that bacterial DNA occurred in all root canal samples. qPCR showed a similar incidence of bacteremia between patients who received or did not receive prophylactic antibiotic therapy (P > .05). In blood samples taken 5 minutes after endodontic procedures, bacteria were detected in 2 of 11 (18%) individuals not taking antibiotics and in 4 of 21 (19%) patients under prophylaxis. After 30 minutes, the incidence of bacteremia decreased to 2 of 21 (10%) in patients taking antibiotics and was undetectable in patients at no risk of IE. The incidence of bacteremia by streptococci was identical as that for total bacteria. ConclusionsNo detectable bacteremia was evident by culture after treatment of infected root canals. Molecular analysis revealed bacterial DNA and streptococci in blood from some patients without a significant difference between individuals receiving or not receiving antibiotic prophylaxis.

Apport de la tomographie par émission de positons au 18-FDG dans l’endocardite infectieuse sur valves et dispositifs implantables : à propos d’une série rétrospective monocentrique de 35 patients

IntroductionInfective endocarditis (IE) is a serious disease whose diagnosis is often difficult. PET 18F-FDG has great potential in this indication, since it has already shown its contributions in the field of inflammation and infection. The objective of this study is to assess the contribution of PET in suspicion of IE in patients with prosthetic heart valve or implantable intracardiac devices. Patients and methodsThis is a single-center, retrospective study in nuclear medicine department of Georges-Pompidou European hospital in Paris between May 2012 and May 2015. Patients were included for suspicion of IE of prosthetic heart valve or implantable intracardiac devices. The diagnosis of IE was based on histological data or monitoring up to 6 months. The clinical, laboratory, ultrasound and microbiological data were collected and analyzed for each patient. The results of PET by visual and semi-quantitative analysis were compared to the final diagnoses. ResultsThirty-five patients were included in the study, with 23 suspected of infection on cardiac valve and 12 suspected of infection on intracardiac device. The final diagnosis of IE was confirmed in 13 patients. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of IE were respectively 92%, 77%, 71%, 94% and 83%. There was a significant difference for the SUVmax ratio (infected site/surrounding noice) for IE groups confirmed vs unconfirmed IE. It was not revealed other factors that could potentially influence the diagnostic performance. ConclusionPET provides a very good sensitivity and a rather good specificity in diagnosis of IE. The results are consistent with the findings of the current literature. The validity of this imaging technique should be confirmed in a prospective clinical study with a larger number of patients.

Trends in incidence of infective endocarditis at the Medical Center of Alkmaar.

IntroductionInfective endocarditis (IE) is a life-threatening illness with a high morbidity and mortality, and with a rise in incidence in patients with prosthetic valves and cardiac devices. Recently the Dutch guidelines of IE prophylaxis have been revised, limiting IE prophylaxis to the highest-risk population. The aim of the present study was to investigate the incidence of IE and its trend between 2008–2013 in a regional hospital in the Netherlands.MethodsThis is an observational descriptive study of all patients who were admitted with IE to the Medical Center of Alkmaar (MCA) from 1 January 2008 to 31 December 2013.ResultsA total of 89 patients with IE, including 7 patients (7.9 %) with a cardiac device IE (CDIE), were identified. In 2008 there were 8 patients with IE, this increased to 26 patients in 2013. Patients with a prosthetic valve IE increased from 25 % in 2008 to 34.6 % in 2013. This increase was not seen in patients with CDIE.ConclusionIn the MCA we have observed an increase in patients with IE since 2010. This increase was in part attributable to prosthetic valve IE. A larger observational study is needed to investigate the increase of IE in the Netherlands.

Endocardite infectieuse aortique : intérêt de la chirurgie. À propos de 48 cas

IntroductionInfective endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic location is characterized by its evolution toward myocardial failure and the high number of complications reasons for early surgery. AimTo compare the short- and mid-terms results of surgery for aortic infective endocarditis (IE) in the active phase and the healed phase. Patients and methodsWe analyzed retrospectively the data of 48 consecutive patients operated for aortic infective endocarditis between January 2000 and January 2012. The data on operative mortality, morbidity and major cardiovascular events (mortality, recurrent endocarditis, reintervention, and stroke) were analyzed. ResultsTwenty-three patients (48%) underwent surgery during the active phase (group I), 19 on native and 4 on prosthetic valves, and 25 patients (52%) were operated during healed endocarditis (group II) only on native valve. Mean age was 39 years (12–81) with a male predominance (83%). Rheumatic valvular disease was the main etiology of underlying valvular disease in both groups (85%). The clinical feature was dominated by signs of cardiogenic shock in group I and dyspnea exertion stage III–IV NYHA in group II. Streptococcus and Staphylococcus germs were most frequently encountered. Indication for surgery was heart failure in group I, it was related to the symptoms, the severity of valvular disease and its impact on the left ventricle in group II. An aortic valve replacement with a mechanical prosthesis was performed in the majority of cases (83%). Postoperative mortality concerned only one patient in group I. Twenty-one patients (44%) were followed for a mean of 30 months (1–72). One patient in group II died following cerebral hemorrhagic stroke related to accident with vitamin K antagonist. In both groups, there was an improvement in the functional class. No recurrence of endocarditis was noted in both groups during follow-up. ConclusionThe prognosis of infective endocarditis of the aortic valve is severe due to the fast progression to heart failure. Early medical and surgical approach provides good results on morbidity and mortality in the short- and mid-terms.

Infective endocarditis in Ethiopian children: a hospital based review of cases in Addis Ababa.

IntroductionInfective endocarditis is an infection of the endocardial lining of the heart mainly associated with congenital and rheumatic heart disease. Although it is a rare disease in children, it is associated with high morbidity and mortality; death due to infective endocarditis has been reported to be as high as 26% in sub-Saharan Africa.MethodsThis was a retrospective review of routinely collected data from patient records.ResultsA total of 40 children (71% female) with 41 episodes of infective endocarditis admitted to a general paediatric ward in Addis Ababa, Ethiopia between 2008 and 2013. Age ranged from 7 months to 14 years, with a median of 9 years (Inter quartile Range: 7-12 years). Rheumatic and congenital heart diseases were underlying risk factors in 49% and 51% of cases respectively. Congestive heart failure, systemic embolization and death occurred in 66%, 12% and 7.3% respectively. Death was associated with the occurrence of systemic embolization (P-value = 0.03).ConclusionRheumatic heart disease was an important predisposing factor for infective endocarditis in Ethiopian children. Late presentations of cases were evidenced by high proportion of complications such as congestive heart failure. A low rate of clinically evident systemic embolization in this study may be a reflection of the diagnostic challenges. High proportion of prior antibiotic intake might explain the cause of significant BCNE. Preventive measures like primary and secondary prophylaxis of rheumatic fever may decrease the associated morbidity and mortality. Early detection and referral of cases, awareness creation about indiscriminate use of antimicrobials, and proper history taking and documentation of information recommended.

Granulomatosis with Polyangiitis (Wegener Granulomatosis) Mimicking Infective Endocarditis

Introduction Infective endocarditis (IE) has been reported to mimic granulomatosis with polyangiitis (GPA) and to test positive to antineutrophil cytoplasmic antibodies (ANCA), which may lead to a misdiagnosis and inappropriate treatment. Case presentation We report a case of a 59-year-old man admitted for purpura, gangrenous digital infarcts and glomerulonephritis. The diagnosis of IE was initially considered on the basis of heart murmur and two positive haemocultures to corynebacterium. Ineffectiveness of antimicrobial therapy and further neurological and nasal manifestations supported the diagnosis of GPA. Conclusions IE should be ruled out before initiation of immunosuppressive treatment. If the disease progresses despite antimicrobial treatment, vascular diseases should be rapidly taken into account in differential diagnosis and treated early to avoid fatal complications.

Les endocardites infectieuses chez l’enfant africain subsaharien, étude transversale à propos de 19 cas à Ouagadougou au Burkina Faso

IntroductionInfective endocarditis is a transplant of a microorganism on a most often injured endocardium. It is rare in children. This work aimed to determine the frequency of endocarditis of the child, to describe clinical presentation, data from echocardiography, microbiological profile and clinical course. Patients and methodsFrom May 1 2010 to April 30 2011, we consecutively included children received for infective endocarditis in two medical centers in the city of Ouagadougou: Saint-Camille medical center and teaching hospital Yalgado-Ouedraogo. We investigated the functional and general signs and treatment already received. The physical examination looking for an infectious syndrome, pneumonia, heart failure and entrance doors. Blood cultures, blood count, creatinine, blood chemistry, HIV status, electrocardiogram, chest radiography and cardiac Doppler ultrasound were systematic. The diagnosis of the disease was based on Duke criteria. ResultsNineteen endocarditis in children were reported, that is 1.7% of admissions. The average age was 4.7±2.6 years (extremes: 1 and 14). The sex ratio was 1.7 for girls. The clinical presentation was a common infectious syndrome. Impaired general condition and congestive heart failure were present on admission in six cases, respectively. The front door was dental in nine cases (47.4%), skin in four cases (21%) and ENT in three cases (15.8%). A peripheral vein was implicated in one case. In the two other cases, no front door had been found. HIV serology was positive in four cases. As for the blood cultures, they were positive in 13 cases. The germs found were Streptococcus in 10 cases and staphylococcus in three cases. Echocardiography had revealed vegetations in 18 cases. These vegetations were localized on the mitral in nine cases. Multiple locations were found in four cases. Underlying heart disease was dominated by rheumatic valve disease (68.4%), healthy heart forms were found in two cases. Treatment consisted of antibiotics, antipyretic treatment and that of heart failure as appropriate. The evolution was marked by five deaths (26.3%) in an array of septic shock. Death was more important in congenital heart disease. ConclusionInfective endocarditis of the child is common in our practice. The clinical syndrome is common infectious. Streptococcus and Staphylococcus are the two germs found. The main door is dental. Hence, dental care should be promoted for better prevention of infective endocarditis in our context.

A randomised clinical trial of comprehensive cardiac rehabilitation versus usual care for patients treated for infective endocarditis—the CopenHeartIE trial protocol

IntroductionInfective endocarditis (IE) is among the most serious infectious diseases in the western world. Treatment requires lengthy hospitalisation, high-dosage antibiotic therapy and possible valve replacement surgery. Despite advances in treatment,...